"Our experience indicates that good Asthma Care Management can prevent up to
99% of children's asthma hospitalizations, and 95% of emergency visits.
In children’s asthma it works better for everyone – and even costs less – to do the
right thing, rather than do the wrong thing over and over and over again.”
– Guillermo Mendoza, MD, Chief, Dept of Allergy, Kaiser Permanente Napa-Solano
Executive Summary
The current approach towards asthma care for children focuses on brief, late-stage treatment, after children are already experiencing asthma attacks. In contrast, Asthma Care Management emphasizes accurate diagnosis, treatment, and preventive care over time. A health team assists families to manage and prevent asthma episodes, while providing education to teach self-management skills. This team approach allows for a broader role for non-physicians such as nurses, respiratory therapists and community health workers.
Asthma Care Management programs give better care at the same or lower cost. These programs:
- Reduce emergency room, acute care visits and hospitalizations;- Reduce school absenteeism, and
- Have shown cost neutrality, or in some cases, significant cost savings.
Childhood asthma is an epidemic in California. 1.4 million children—14.8% of all the state's children --are now affected. (1) Some counties in California report that up to one out of four children have asthma.(2) The prevalence of asthma ranges across ethnic groups: it is highest among African Americans and American Indian/Alaskan Natives (22.6% and 22.2% respectively), with White, Latino, and Asian groups following at 15.1%, 13.1%, and 11.4% respectively.(3)
The costs to individual children and their families are staggering. Each year over 136,000 children must seek emergency treatment for asthma care. (4) Asthma is also the leading cause of school absences among all chronic conditions. Affected children miss out on their education and their absences cost schools tens of millions of dollars per year in lost funding. For California children ages 12-17 alone, the California Department of Health Services estimates a loss of $40.8 million to schools from preventable absences due to asthma in 2001.(5)
The state and the nation also suffer. The average cost of hospitalization for a child with asthma on Medi-Cal is $12,395.(6) Asthma costs California approximately $1.3 billion per year, with Medi-Cal paying approximately 45% of the cost of care for children.(7) Most of these expenditures are concentrated within a small group. National Medicaid data shows that the 25% of children with the most severe asthma cost 28 times as much as the least-severe quartile of children with asthma.(8)
Due to scientific advances over the last twenty years, nearly all suffering and related costs are preventable. Asthma Care Management combines accurate diagnosis, preventive medical care, family health education, and assistance to help families reduce their children's exposure to asthma triggers. The National Institutes of Health has had widely accepted national clinical guidelines in place since 1991.(9)
Yet, current health care reimbursement policies do not adequately support chronic care management. As a result, many children are repeatedly prescribed ineffective cough medicines and short-acting rescue medication, leaving these children and their families in a life-threatening--and expensive--“emergency room revolving door.” One recent study, for instance, found that 58% of inner city children were not prescribed the necessary long-term controller medications.(10) On average, 72% of all persistent asthmatics care for in California physician groups do not use the indicated medications.(11)
“Physicians and hospitals are better funded to admit a child with a near-fatal asthma attack to intensive care, than to prevent the attack before it starts. We know how to prevent serious and expensive complications of chronic disease, but we are not doing it.”
Thomas Bodenheimer, MD, Professor of Family and Community Medicine, University of California, San Francisco.
As the most populous state in the U.S.--home to one out of five children in the nation-- California has the opportunity to lead the nation in addressing the unnecessary suffering and high cost of childhood asthma. The challenge is to provide adequate financing for the comprehensive outpatient services needed to stabilize high-risk children.
The Solution: Children’s Asthma Care Management
Through Asthma Care Management, the health of children with asthma can significantly improve and limited resources can be used most efficiently. It is now possible to forestall nearly all asthma episodes and hospital days for children with asthma. This has been shown by a series of grant-funded California demonstration projects, by extensive data from Kaiser Permanente Northern California, and by numerous studies and field trials (see summary of the evidence below).
Asthma Care Management differs from traditional treatment in three major ways. It:
- Provides wrap-around services designed to prevent asthma attacks and promote self-management (for example, hypoallergenic bed encasements; enhanced health education; home environmental assessments; and training for self-management).
- Tracks children over time before they get acutely ill, in a series of preventive clinic visits.
- Uses Asthma Care Teams comprised of physicians/nurse practitioners, registered nurses or respiratory therapists, community health workers and others.
Team members and their responsibilities are as follows:
- The Physician/Nurse Practitioner assesses symptoms, makes diagnoses, determines the severity level, and prescribes medicines. He or she leads the clinical team and quality assurance endeavors.
- The Clinical Care Coordinator (typically a registered nurse or respiratory therapist) coordinates the team’s daily work, ensures continuity, provides case management, educates the family about self-management, and tracks medication use.
- The Community Health Worker reinforces health education and skills in language the family understands, provides culturally competent support for self-management, and helps the family minimize asthma triggers.
There are many ways to configure the service delivery of Asthma Care Management for various settings, from large community-based clinics to children's hospitals to small private practices. The important consideration revealed through a national scan of asthma programs is that care management be located in or very closely linked to the child's medical home. Remote or telephone-based disease management programs further fragment children's care.
Not all children with asthma require Asthma Care Management; 75% are adequately treated through traditional clinical services. While all children with suspected asthma should be assessed, only about a fourth of children with the worst cases of asthma need Asthma Care Management. (13) The intensity of that care children need varies, and is calibrated to the severity of their asthma (see diagram (14)). Once a high risk child is stabilized, generally within six months, he or she can return to receiving care from a primary care provider only.
The Evidence: Asthma Care Management Reduces Symptom Days, Medical Care Utilization
and Expenditures, and Decreases School AbsenteeismA large body of evidence demonstrates that this type of intervention can improve health and reduce hospital and emergency admissions, for the same or lower costs.
Both Kaiser Permanente (15) and the Harlem Children’s Study (16) found significant decreases in utilization, in Kaiser Permanente, sometimes in as little as a few weeks. In the Harlem Children’s Study,
- Emergency department and unscheduled physician visits dropped by 77%,
- Hospitalization decreased from 8.6% to 0%; and
- Total school absenteeism dropped in half, while absenteeism for asthma in particular dropped by nearly two thirds.
San Francisco General Hospital's Pediatric Asthma Clinic demonstrated that asthma care management reduced symptom days and increased activity levels for children.(17) Preliminary results from and evaluation of the clinic's work,(18) and evaluations of the "California Asthma Among the School Aged Initiative" (CAASA),(19) and the "Childhood Asthma Initiative"(20) have shown reductions in utilization, including hospitalizations, emergency department use, and unscheduled clinic visits. Preliminary data from the latter two programs documented reductions in costs. The Childhood Asthma Initiative found expected net savings for each child of:
- $426 from reduced emergency department visits,
- $1072 from fewer hospital admissions; and
- $1199 from total cost of treatment.
The Inner-City Asthma Study, conducted in seven urban locations across the United States, used a home-based intervention to reduce environmental triggers. During the two-year study, each child in the intervention had about 38 more symptom free days, at a cost of about $28 per day.(21)
The Future for California: How Do We Implement Asthma Care Management?
California can establish a system for care and appropriate reimbursement that ensures that Asthma Care Management becomes the standard operating procedure statewide for high need children.
Kevin Grumbach, MD, Chair of Family and Community Medicine at UCSF states, “With the evidence that has accumulated, we should no longer be focusing on ‘Should we implement this approach?’ Rather our discussions should center on the question, 'How can we change our reimbursement system so that community-focused chronic care can go to scale as rapidly as possible?' The conversation needs to shift from 'Should we do it?' to 'Why have we not done this already?'”
Asthma Care Management utilizes a team which works with busy clinicians to handle routine aspects of chronic care and follow-up, and spend more time on family education. To treat the sickest children effectively, reimbursement for asthma care must allow for this team approach and support non-clinical wrap-around services. Two options for addressing these issues include: setting standards for health plans for the provision of these services, and/or revising reimbursement systems for services, particularly under managed care. Potential reimbursement strategies are outlined below:
The Prospective Payment System: The Prospective Payment System (PPS) is a procedure the California Department of Health Services (DHS) uses to reimburse community clinics for the global costs of providing health care. Clinics may renegotiate a higher rate with DHS if they expand their scope of services—for example, if they add a dental clinic. Under this option, community clinics would be actively encouraged to apply to DHS to add Asthma Care Management to their scope of services. This would result in a new higher rate that would cover the costs of the program. (If fully implemented statewide, this mechanism would cover about three out of ten low-income children, those seen at community clinics.)
Specifically, DHS could: add Asthma Care Management to a guidance letter listing the types of services qualifying for a scope of service expansion; provide technical assistance to clinics considering the Scope of Service expansion; grant funds to clinics to support the initial start-up costs of an asthma management program. A start-up kit of protocols, materials and trainings could be provided to clinics wanting to pursue the expanded Scope of Service.
Risk-Adjusted Capitation: To minimize financial disincentives to provide high need children with appropriate asthma services like those prescribed in the Asthma Care Management model, capitation rates can be adjusted not only by age, sex, geographical location and eligibility category (all of which are currently required by the federal Center for Medicare and Medicaid Services) but also by health status, allowing for adequate payment to plans and providers for necessary services. Two systems, Adjusted Clinical Groups (ACGs) and Asthma Illness and Disability Payment System (CDPS), have been implemented in Medicaid programs in several states and could be adapted for the purpose of ensuring that children with a high need for care receive cost effective services.
Asthma Management Fees: Medi-Cal has an easy-to-use mechanism to support providers to give more intensive services to patients with complex conditions. Across the nation such “management fees” are widely used in mental health, substance abuse, dental, vision, prescription drugs and organ transplants. Asthma management for children meeting high-risk criteria would simply be added to this list. The provider would receive payment from Medi-Cal upon verified completion of a well-defined protocol. The amount of the fee would be based on a sliding scale reflecting the severity of the child’s condition and the associated level of services according to a proposed risk stratification protocol. (Additional information on the Risk Stratification Protocol is available upon request from the authors.)
Comprehensive Perinatal Services Program Look-Alike: CPSP is a successful statewide program for pregnant women that tracks patients over time and uses a team model, including community health workers to reinforce health education. Such services are paid fee-for-service in addition to capitation payments.
Linking Future Special Funding to Update Reimbursement: Short-term special funds from public or private sources could be used as an incentive to health plans which agree to make permanent changes to strengthen outpatient care. Based on the experience of Kaiser Permanente and California demonstration projects, this investment would "prime the pump," enabling the plans to implement Asthma Care Management for high-risk children and to realize the anticipated reduction in emergency and hospital expenditures. This approach was followed in New York State using grant funding from the Robert Wood Johnson Foundation as an incentive for permanent large-scale change.(22)
Summary and Conclusion
California has the opportunity to lead the nation in improving the health of children with unstable asthma. Asthma Care Management can improve health and school attendance, prevent hospitalizations and save limited state dollars. Ensuring that the sickest children with asthma receive Asthma Care Management will benefit the children, their families and all Californians. Researchers from the University of California, San Francisco, and San Francisco State University have prepared additional materials that outline these issues in greater detail, available upon request.
Co-signers as of today’s date:
Joel Adelson, MD, PhD, Chief of the Integrating Medicine and Public Health Program, (UCSF) *
Tom Bodenheimer, MD, Professor of Family and Community Medicine, UCSF
Kevin Grumbach, MD, Chair, Dept of Family and Community Medicine, UCSF
Mary Beth Love, Ph.D., Department Chair, Health Education, SFSU
Jim Mangia, Chief Executive Officer, St. John’s Well Child and Family Center, LA
Elisa Nicholas, MD, Executive Director, The Children’s Clinic Serving Children and Their Families, Long Beach
Shannon Thyne, MD, Medical Director, Pediatric Asthma Clinic at SFGH/UCSF
Contact information:
Vicki Legion, vlegion@sfsu.edu, 415 235 0300
Jeni Miller, jlmiller@sfsu.edu
Mary Kreger, mary.kreger@ucsf.edu
* Organizational affiliation is for identification purposes only.
Fn: ___Brief 06 0608 FINAL.pdf
1 Lund, L.E. Asthma in Children and Adolescents in California Counties, 2003. California Department of Health Services, Center for Health Statistics, 2005.
2 Ibid.
3 California Health Interview Survey, 2003. (Note: The total percent, including "other single/two or more races" adds up to 103.6%.)
4 Ming, YY, Babey, SH, et .al., Asthma in California: Findings from the 2001 California Health Interview Survey, University of California, Los Angeles Center for Health Policy Research,2003.
3 Center for Health Care Strategies, Asthma Care for Children: Financing Issues, A CHCS Chartbook, October 2001, Figure 2-2.
4 Allergy and Asthma Foundation of America, 1998.
5 California Department of Health Services, Guidelines for the Management of Asthma in California Schools: A comprehensive resource for school health and other personnel to address asthma in the school setting, April 2004. http://www.caasthma.org/files/dhsASTHMAguidelinesFINAL.pdf.6 2003 Office of Statewide Health Planning Data, Discharge Data for Asthma, Children Aged 0-18 Years Old.
7 Allergy and Asthma Foundation of America, 1998.
8 Center for health Care Strategies, Asthma Care for Children: Financing Issues, A CHCS Chartbook, October 2001, p. 11 and 27.
9 National Asthma Education and Prevention Program Expert Panel Report: guidelines for the Diagnosis and Management of Asthma: Update on Selected Topics 2002. Full report: www.nhlbi.nih.gov/guidelines/asthma/asthmafullrpt.pdf, Practical Guide for the Diagnosis and Management of Asthma, NIF, NHLBI, October 1997, www.nhlbi.nih.gov/health/prof/lung/asthma/practgde/practigde.pdf. James Stout, MD, MPH, National Initiative on Children’s Healthcare Quality, vice president leading asthma programming.
10 Butz, A.M., Eggleston, P.A., Huss, K., Rand, C.S., Riekert, C.A., Winkelstein, M., "Caregiver-Physician Medication Concordance and Under Treatment of Asthma Among Inner-City Children," Pediatrics, Vol. 111, No. 3, March 2003, P. 217.
11 Bodenheimer, T., Examining Chronic Care in California's Safety Net, California HealthCare Foundation, July 2003, www.chcf.org.
12 Personal communication, October 2005.
13 Stout, J., MD, MPH, Vice President, National INitiative on Children's Healthcare Quality, and technical advisor to numerous statewide asthma quality improvement collaboratives.
14 Mendoza, Guillermo, Presentation at American Public Health Association Meeting in San Francisco, CA, 2003.
15 Mendoza, Guillermo, Presentation at American Public Health Association Meeting in San Francisco, CA, 2003. This research included over 26,000 individuals and covered 3 years.
16 Reducing Childhood Asthma Through Community-Based Service Delivery, New York City, 2001--2004, Morbidity and Mortality Weekly Review, January 14, 2005 /54(01); 11-14.
17 Thyne, S., Rising, J.P., Legion, V., Love, M.B., The Yes We Can Asthma Partnership: A Medical/Social Model for Childhood Asthma Management, Journal of Asthma, forthcoming. The YES WE CAN demonstration project was funded by The California Endowment. This is one of only six evidence-based interventions extensively profiled by the Centers for Disease Control at http://www.cdc.gov/nceh/airpollution/asthma/interventions/interventions.htm;18 Kreger, M., Thyne, S., Kao, C., Colon-Hopkins, C., Brindis, C., Cost-Effectiveness Study of San Francisco General Hospital Pediatric Asthma Clinic, 2006, preliminary data. Funded by The California Endowment and the California Program on Access to Care.
19 Funded by The California Endowment, 2001-2004
20 Funded by the First Five Commission, 2000-2005
21 Kattan, M., Stears, S.C., Crain, E.F., Stout, J.S., Gergen, P.J., Evans III, R., et .al. Cost Effectiveness of a Home-Based environmental Intervention ofr Inner-City Children with Asthma. Journal of Allergy and Clinical Immunology 2005; 116: 1058-63.
22 Interview with Jay Portnoy, M.D., Medical Director of Health Management, Children's Mercy Hospitals and Clinics, Kansas City Missouri, April 4, 2006.
Last updated 7/21/2006.
